Provider Demographics
NPI:1578825881
Name:COOPER, LISA M
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 DAVID AVE
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3346
Mailing Address - Country:US
Mailing Address - Phone:607-768-1477
Mailing Address - Fax:
Practice Address - Street 1:4400 VESTAL PARKWAY EAST BINGHAMTON UNIVERSITY
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13902
Practice Address - Country:US
Practice Address - Phone:607-777-2829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634608051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist